Universal health coverage: Measuring the path to progress

The ongoing global initiative to expand universal health coverage (UHC), especially in low- and middle-income countries, is heartening, as is positioning UHC as a focus of the post-2015 development agenda. Most of us hope that UHC will make a real improvement in health status, in addition to expanding population coverage of health services.

When it comes to measuring UHC, of course, the final outcomes at the national and global level (i.e. access to services, effective coverage of services, financial risk-protection) are key. However, we need to consider the fact that there are limited capacities in many low- and middle-income countries within the institutional framework, building blocks of health systems, coordination of funding, harmonization of health interventions and inter-sectoral collaboration. Therefore, tracking the factors affecting progress of UHC, apart from merely measuring “UHC status,” is inevitable.

In this context, while developing measurement strategies, it is sensible to consider process indicators along the path to progress. At the country level, if certain process and intermediate indicators (e.g., % of community health workers engaged in hypertension or diabetes screening) are not measured as part of UHC, countries will not be able to internalize factors affecting progress and address the gaps timely. Nevertheless, a country needs to adopt a careful selection of process indicators, balancing with the end target, so as not to be sidetracked into solely tracking progress.

Qualitative outcomes are similarly relatable for the real measurement of UHC. For instance, ensuring ‘acceptable care’ for people remains a part of the National Health Strategy of many countries, especially for reproductive health issues, and for physically challenged and indigenous populations. Many countries still adhere to the Alma Ata Declaration and value health as a fundamental right of the people. Understanding the factors affecting “people’s need for appropriate care” and “acceptance for currently available care” under the socio-cultural context is a stepping stone to enhance effective coverage of services. On the supply side, effective coverage is influenced by factors such as managerial efficiency and provider motivation. Collecting qualitative evidence will also help us understand the contextual factors affecting the progress towards UHC and take corrective action.

Tracking how a country addresses ‘social determinants of health’ needs to be part of UHC measurement. When it comes to equity, it is relevant to factor in how each initiative fixes its targeting and identifies the beneficiaries. In reality, the experiences of many countries in social protection and health indicate that the poorest of the poor are often excluded from coverage due to administrative difficulties in targeting.

Finally, it makes sense to strategize on identifying relevant data sources. Broadly, there could be two data sources: (a) routine administrative data and (b) periodic surveys. Administrative data has limitations on selection of services and indicators, accuracy of information and timeliness of reporting. A holistic approach to improve the quality of administrative data and align it with UHC targets would be prudent for the measurement of progress.

Periodic surveys such as demographic and health surveys (DHS) or multiple indicator cluster survey (MICS) currently focus on sexual, reproductive and child health. The scope of these studies could be expanded to include: (a) services related to non-communicable diseases, mental health and injuries; (b) the elderly population; (c) information on out-of-pocket expenditures on key health conditions; and (d) satisfaction of clients with services.

Qualitative data collection could piggyback on these surveys on a fairly small scale. In several countries, financial risk protection and nutrition indicators are often under the purview of multiple ministries. It may be good to have national-level identification and consensus on key sources of data.

To conclude, built-in and ongoing collection and tracking of quantitative and qualitative data may be suitable for country-specific UHC measurement. Though tracking process and qualitative indicators is context-specific, it would be efficient to design a set of global measures to track countries embarking on UHC. Building capacities of the National Health Research Unit for UHC measurement could be a potential idea in the medium- to long-term for several low- and middle-income countries.